Hsian-Jenn Wang

Reconstruction of burn scar of the upper extremities with artificial skin.

The management of upper‐extremity burn contractures is a major challenge for plastic surgeons. After approval by the Food and Drug Administration, artificial skin (Integra) has been available in Taiwan since 1997. From January of 1997 to July of 1999, the authors applied artificial skin to 13 severely burned patients for the reconstruction of their upper extremities, resulting in an increased range of motion in the upper‐extremityjoints and improved skin quality. An additional benefit was the rapid reepithelialization of the donor sites. There were no complications of infection throughout the therapeutic course, and the overall results were satisfactory. During the 2‐year study, scar condition was monitored between 8 and 24 months, and a good appearance and pliable skin were obtained according to the Vancouver Scar Scale. According to this evaluation of Oriental skin turgor, normal pigmentation was restored about 6 months after the resurfacing procedure. For patients with severe burns in whom there is insufficient available skin for a full‐thickness skin graft or another appropriate flap for scar revision, Integra is an alternative. The two major concerns in dealing with artificial skin are (1) a 10‐ to 14‐day waiting period for maturation of the neo‐dermis, necessitating a two‐stage operation, and (2) prevention of infection with antibiotics and meticulous wound care. (Plast. Reconstr. Surg. 108: 378, 2001.)

Distally based sural fasciomusculocutaneous flap for chronic calcaneal osteomyelitis in diabetic patients.

Chronic calcaneal osteomyelitis is a difficult surgical problem, especially in diabetic patients. After aggressive surgical eradication of nonviable soft tissue and infected bone, there will be a large soft-tissue and bony defect. A distally based sural fasciomusculocutaneous flap including the sural nerve and a midline cuff of the gastrocnemius muscle can be useful for covering the defect. This flap is designed on the proximal half of the posterior calf and has an adequate blood supply derived from retrograde perfusion of the vascular axis of the sural nerve to the musculocutaneous perforators of the gastrocnemius muscle. The patency of the peroneal artery should be confirmed by Doppler ultrasound or angiography before surgery. If there are any vascular problems, this flap will not be used to avoid complications resulting from poor flap circulation. This approach has been used for 11 diabetic patients in the past 2 years. All flaps survived completely and all wounds healed uneventfully. The authors found that the flap was reliable and technically simple to design and execute. This 1-stage procedure not only preserves the major arteries of the injured leg but has also proved valuable for filling bony defect and treating bony infection because it provides a well-vascularized muscle fragment. Compared with other tissue transfers, this flap has special characteristics for use on diabetic patients with chronic calcaneal osteomyelitis.

The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction.

&NA; Finding an appropriate soft‐tissue grafting material to close a wound located over the ankle and heel can be a difficult task. The distally based lesser saphenous venofasciocutaneous flap mobilized from the posterior aspect of the upper leg, used as an island pedicle skin flap, can be useful for this purpose. The vascular supply to the flap is derived from the retrograde perfusion of the accompanying arteries of the lesser saphenous vein. These arteries descend along both sides of the lesser saphenous vein to the distal third of the leg, either terminating or anastomosing with the septocutaneous perforators of the peroneal artery. Between February of 1999 and March of 2001, four variants of this flap were applied in 21 individuals, including 11 fasciocutaneous, five fascial, three sensory, and two fasciomyocutaneous flaps. Skin defects among all patients were combined with bone, joint, and/or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one‐stage procedure not only preserves the major arteries and the sural nerve of the injured leg, but it also has proved valuable for covering a weight‐bearing heel and filling a deep defect, because it potentially provides protective sensation and a well‐vascularized muscle fragment. When conventional local flaps are inadequate, this flap should be considered for its reliability and low associated morbidity. (Plast. Reconstr. Surg. 110: 1664, 2002.)

The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries.

Over the last half century, advances in treatment have changed the principal cause of death in burn patients from burn shock and wound sepsis to pulmonary sepsis, of which inhalation injury has always played a key role in morbidity and mortality. Even though Navar et al., Am. J. Surg. 1985;150:716-720 have noted that patients with inhalation injury had a mean fluid requirement of 5.8 ml/kg/% burn to achieve resuscitation from early burn shock, while patients without inhalation injury required only a mean fluid of 4.0 ml/kg/% burn, to achieve successful resuscitation in inhalation injured patients with minimum but adequate fluid has always been a challenge. To further define the difference of early fluid therapy between inhalation and noninhalation in extensively burned patients, a retrospective analysis was carried out in the Tri-Service General Hospital. Sixty-two flame burned patients (aged from 16 to 81 years-old with a mean age of 33.2+/-15.1 years: with burn size ranging from 30% to 98% TBSA with a mean burn size of 60.5+/-22.7%; 26 with inhalation injury; noninhalation 36) were reviewed during a 5-year period. The Parkland formula is the initial choice of fluid regimen with 4 ml/kg/% burn and the amount of replacement is monitored by urine output and is titrated to maintain urine output between 0.5 and 1.0 ml/kg/h. The mean amounts of fluid requirements of both inhalation and noninhalation burned patients were 3.1 +/- 1.0 and 2.3+/-0.8 ml/kg/% burn respectively (p < 0.05). Our study showed less fluid requirement for both inhalation and noninhalation injured patients in comparison with the Navar study and Parkland predictions in the first 24 h postburn. Furthermore, the inhalation injured patients definitely required volumes of fluid in excess of those required in noninhalation injured cases.

The management of white phosphorus burns

Phosphorus burns are a rarely encountered chemical burn, typically occurring in battle, industrial accidents, or from fireworks. Death may result even with minimal burn areas. Early recognition of affected areas and adequate resuscitation is crucial. Amongst our 2765 admissions between 1984 and 1998, 326 patients had chemical burns. Seven admissions were the result of phosphorus burns. Our treatment protocol comprises 1% copper sulfate solution for neutralization and identification of phosphorus particles, copious normal saline irrigation, keeping wounds moist with saline-soaked thick pads even during transportation, prompt debridement of affected areas, porcine skin coverage or skin grafts for acute wound management, as well as intensive monitoring of electrolytes and cardiac function in our burns center. Intravenous calcium gluconate is mandatory for correction of hypocalcemia. Of the seven, one patient died from inhalation injury and the others were scheduled for sequential surgical procedures for functional and cosmetic recovery. Cooling affected areas with tap water or normal saline, prompt removal of phosphorus particles with mechanical debridement, intensive monitoring, and maintenance of electrolyte balance are critical steps in initial management. Fluid resuscitation can be adjusted according to urine output. Early excision and skin autografts summarize our phosphorus burn treatment protocol.

Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb

Finding an appropriate soft-tissue grafting material to close a wound located over the distal phalanx of the thumb, especially the pulp region, can be a difficult task. A sensate first dorsal metacarpal artery flap, mobilized from the dorsum of the adjacent index finger and used as an island pedicle skin flap, can be useful for this purpose. The pedicle includes the ulnar branch of the first dorsal metacarpal artery, the dorsal veins, and the cutaneous branch of the radial nerve. Although this tiny artery is anatomically variable, safe dissection can be achieved by including the radial shaft periosteum of the secondary metacarpal bone and the ulnar head fascia of the first interosseous muscle. This approach has been used for 8 individuals with extensive pulp defects of the thumb over the past 3 years. Skin defects in all patients were combined with bone, joint, or tendon exposure. All flaps survived completely. This 1-stage procedure is reliable and technically simple. It provides sensate coverage to the pulp of the thumb but also avoids nerve repair or more complicated microsurgery.

Evaluation of a novel malleable, biodegradable osteoconductive composite in a rabbit cranial defect model

Abstract The ceramic form of calcium phosphate osteoconductive material such as hydroxyapatite is brittle, non-malleable and non-degradable, and these mechanical properties limit its clinical application in calvarium reconstruction. To improve these properties, we developed a malleable, biodegradable osteoconductive composite composed of tricalcium phosphate particles bound by a gelatin which is set by glutaraldehyde mediated cross-linking. The composite was implanted into a 15 × 15 mm full-thickness, calvarial defect in 20 rabbits for up to 3 months. Twelve rabbits were left unreconstructed as controls. Specimens were retrieved at 2 weeks, 1, 2 and 3 months. Five reconstructed and 3 unreconstructed rabbits were examined for each time period. The assessment included a series of post operative gross examinations, radiographs and histologic evaluations. We are able to demonstrate that this composite is (1) biocompatible, with little tissue reaction; (2) osteoconductive, with progressive growth of new bone into the calvarial defect; (3) biodegradable, with progressive replacement of the composite by new bone, acellular matrix and bone-like material. Replacement of this composite by new bone is postulated to occur by a combination of osteoconduction and biodegradation. These results indicate that further experimental research to combine this malleable, biodegradable, osteoconductive composite with an osteoinductive agent such as bone morphogenetic protein may generate new biomaterial for full-thickness calvarial defect reconstruction.

Surgical management of axillary bromidrosis--a modified skoog procedure by an axillary bipedicle flap approach.

We developed a modified Skoog procedure to treat axillary bromidrosis and hyperhidrosis that creates a bipedicle flap over the axillary fold with two parallel incisions to achieve a complete excision of the sweat glands. If necessary, the flap can be extended by making another parallel incision for a larger axillary hair-bearing area. Between 1988 and 1992, 110 patients were operated on using this method, but only 92 of the 110 patients, with an average follow-up period of 29.5 months, were available for this follow-up study. In this series, 86.9 percent of patients gave a family history of axillary bromidrosis. This follow-up review demonstrated that 93.5 percent of patients experienced no odor or occasional very mild axillary odor postoperatively. Postoperative scar formation was either nonvisible or excellent in 95.1 percent of patients, and 82.6 percent of patients reported either a hairless axilla or a marked decrease of axillary hair. Most importantly, 92.4 percent of patients reported a marked decrease in axillary sweat. Four axillary fossae developed postoperative subcutaneous hematomas, and six wounds had mild dehiscence. All of the wounds eventually healed satisfactorily after minor procedures. We concluded that for the treatment of extensive axillary apocrine bromidrosis, this new method achieves complete excision of the sweat glands and provides excellent functional and cosmetic results.

The boomerang flap in managing injuries of the dorsum of the distal phalanx.

Finding an appropriate soft-tissue grafting material to close a wound located over the dorsum of a finger, especially the distal phalanx, can be a difficult task. The boomerang flap mobilized from the dorsum of the proximal phalanx of an adjacent digit can be useful when applied as an island pedicle skin flap. The vascular supply to the skin flap is derived from the retrograde perfusion of the dorsal digital artery. Mobilization and lengthening of the vascular pedicle are achieved by dividing the distal end of the dorsal metacarpal artery at the bifurcation and incorporating two adjacent dorsal digital arteries into one. The boomerang flap was used in seven individuals with injuries involving the dorsal aspect of the distal phalanx over the past year. Skin defects in all patients were combined with bone, joint, or tendon exposure. The authors found that the flap was reliable and technically simple to design and execute. This one-step procedure preserves the proper palmar digital artery to the fingertip and has proven valuable for the coverage of wide and distal defects because it has the advantages of an extended skin paddle and a lengthened vascular pedicle. When conventional local flaps are inadequate, the boomerang flap should be considered for its reliability and low associated morbidity.

Thin split-thickness toenail bed grafts for avulsed nail bed defects.

Avulsed defect of a fingernail bed is a common injury in acute hand trauma. Insufficient management for this type of nail bed avulsion often leads to an irregular and nonadherent nail. The use of thin split-thickness sterile matrix graft from the great toe for immediate replacement of a nail bed defect can regain a smooth, adherent, and normal-looking nail. Between May of 1998 and December of 2001, we used thin split-thickness toenail bed grafts in 13 fingers of 12 patients with avulsed defects of the nail bed. The end results of this technique were excellent and no deformities occurred in the graft donor area. Thin split-thickness toenail bed graft is a good choice for the treatment of acute nail bed avulsion.